Published Sep 16, 2002
Hello:p I was writing b/c i had a few questions for you all! I am a new grad CCU RN and today (my very first day off orientation) I ended up w/ an off service pt and inmate but that is another story!!! The patient came down from the oncology unit to us b/c of respiratory distress. Anyhow, after the patient was stabilized, the MD's still wanted the chemo....which is all fine and I understand that a pt does not want to miss a day of chemo. I had to premedicate the patient and one of the wonderful onc nurses came down to hang the chemo for me....I left today with some questions though and was hoping you could answer them for me.
The patient had AML and had wbc count of 1 in the AM and then .5 six hrs later. Her H/H was 10.8 and 29.5 She was premedicated w/ Zofran, Dexamethosone, and another I cannot remember. She also had to have bicarb running @100. Why bicarb? And what is the rationale behind the premedications? What are u preventing. She was getting two different chemo bags....I meant to write down the names, they didnt sound familiar to me though (not that I know many of them anyhow).
She also had a lot of vaginal bleeding. She was passing alot silver dollar to slightly bigger size clots. Is this common w/ this type of patient? Sorry...these may be dumb questions...I just left today from work w/ alot of unanswered questions.
In addition, I needed to check her urine pH and keep it greater than 7.0. Why is the rationale behind this?
Oh and one more question..... she also needed platlets, count of 8 got 1 u and went up to 21 but she started to have rxn during the transfusion so i shut it off after bout half the way through (what a day!!!)) is this seen often w/ aml patients?
thansk so much for ur help!!!!
-curious new CCU RN
caroladybelle, BSN, RN
Well, it would help to know what the chemos are, but I'll try.
The zofran & decadron are used to help prevent nausea. Phenergan/Compazine are frequently ineffective at treating chemo induced nausea - it is also better to prevent chemo-related nausea than stop it once it starts (pts may develop anticipatory nausea - almost pavlovian). Your best antiemetics are kytril, zofran & anzemet (all new - all terribly expensive). If nausea occurs anyway, recommend IV Ativan 1-2mg Q4 - but watch cumulative sedative effects (unstable half life).
Decadron helps prevent nausea and allows chemo to work better. As it is a steriod, it will also increase appetite, can cause sweats, mask infection, prevent fever, and cause volatile mood swings in patients (not like AML does't have them freaked to begin with).
Typically for AML if the pt has adequate cardiac function, we do Induction 5-8 days of chemo - completely knock out immune system (WBC's<.02 granulcytes in days pts blood counts of them drop. repeated transfusions are necessary neupogen use is generally contraindicated as may increase reproduction leukemic cells. low count period called nadir about and start to return. the pt frequently hospital d anemia neutropenia or opportunistic infection for weeks.>
Anthracytes are cardiotoxic as well as vesicants. monitor IV site patency and heart function carefully.
If CNS leukemia is present, methotrexate may be used. With high dose methotrexate, the urine can become very acidic, the bicarb in the IV is to prevent that. Thus the reason for monitoring the urine pH.
Your big medical risks with this pt is tumor lysis syndrome (monitor lytes), DIC (monitor bleeding), opportunistic infection w/ steroids and immunocompromise masking it ( a temp of >100.5 is considered serious - if you have no WBC's you produce very little temp, no pus, little inflammation - no obvious sx of infection). Severe mouth sores are common.
Other drugs given include allopurinol ( the chemo can increase uric acid), Tagamet for heartburn. When giving blood products to cancer pts, all products should be leukoreduced and if possible irradiated. Platelets are given sparingly, as repeated doses may cause pt to become refractory. Many MDs will give birth control meds to prevent pregnancy and prevent periods that may cause excess bleeding. Many MDs request that all transfusions are preceeded w/tylenol & benedryl. Some antivirals and antibiotics may be given during hospitalization to prophylactically prevent infection.
Hope this helps!!!
I am impressed over the answer you gave to the new CCU nurse!
I am working with the same onch. problems, but high dose MTX 19gram against osteog.sarkoma children patients.
I thought about what you were saying about the urine and PH, and maybe I misunderstood you; They want to get the pH over 7.5 because if the consentration of MTX in the nephrons get pH lower than that, it would be crystall-making there and damage the nephrons; forever. It is so important about that pH, that if we dont follow the urine every time (hour) he want to (I dont know what you call it in hospital-english..)! If the pH is lower than 7.5-7.0; we give iv natriumbicarbonat.:)
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